Longitudinal Healthcare Utilization and Costs in Parkinson’s Disease: Pre-Diagnosis to 9 Years After

Background: There is currently insufficient long-term data on costs of treatment in patients with Parkinson’s disease (PD), which is chronic and progressive, and associated with substantial healthcare costs. Identifying patterns in healthcare utilization and cost may illuminate further discussion on early intervention. Objective: To characterize long-term healthcare utilization and costs of PD in newly diagnosed patients managed by movement disorder specialists. Methods: Using a longitudinal matched-cohort study of linked data from the National Neuroscience Institute Parkinson’s disease and Movement Disorder and healthcare administrative databases in Singapore from 2008–2017, we compared healthcare utilization and costs between patients and controls matched on age, sex, race, and Charlson Comorbidity Index score. Results: 1,162 patients met study inclusion criteria and 1,157 matched controls were identified. The total mean annual healthcare cost (at 2017 costs) was significantly increased in patients compared to controls from years 1–9 post-diagnosis. The increased cost was observed 2 years before diagnosis (USD2322 vs. 2052; p < 0.001). Mean annual cost attributable to PD increased from USD1854 at 1-year post-diagnosis to USD2652 at 9 years. Over 9 years, average costs were significantly higher across all domains of healthcare utilization except primary care—cost of intermediate and long-term care was increased by a factor of 2.5, specialist care by 2.3, emergency department visits by 1.6, and hospital admissions by 1.3. Conclusion: PD results in higher healthcare utilization and costs. Pre-diagnosis increase in healthcare utilization observed in patients supports the presence of prodromal PD symptoms and may present an opportunity for early diagnosis.

Nocardiosis in Japan: a multicentric retrospective cohort study

Background Nocardia species cause a broad spectrum of infections, especially in immunocompromised patients. Given its relative rarity, data on the prognosis and distribution of nocardiosis from a large cohort are scarce. The present study aimed to scrutinize the clinical features and outcomes of nocardiosis in Japan, including one-year mortality and microbiological data. Methods The present, multicentric, retrospective cohort study enrolled patients aged ≥ 18 years with nocardiosis diagnosed between January 2010 and December 2017 and recorded their clinical and microbiological characteristics. Factors associated with one-year mortality were also determined using Cox proportional hazard analysis. Results In total, 317 patients were identified at 89 hospitals. Almost half (155/317, 48.9%) were receiving immunosuppressive agents, and 51 had disseminated nocardiosis (51/317, 16.1%). The one-year, all-cause mortality rate was 29.4% (80/272; lost to follow-up, n = 45). The most frequently isolated species was Nocardia farcinica (79/317, 24.9%) followed by the N. nova complex (61/317, 19.2%). Selected antimicrobial agents were generally effective, with linezolid (100% susceptibility [S]) and amikacin (94% S) having the most activity against Nocardia species. In Cox proportional hazard analysis, factors independently associated with one-year mortality were a Charlson Comorbidity Index score ≥ 5 (adjusted hazard ratio [aHR], 3.61; 95% confidence interval [CI], 1.95-6.71, P < 0.001) and disseminated nocardiosis (aHR, 1.79; 95%CI, 1.01-3.18, P = 0.047). Conclusions The presence of advanced comorbidities and disseminated infection, rather than variations in antimicrobial therapy or Nocardia species, were independently associated with one-year mortality.

Worse outcomes and higher costs of care in fibrostenotic Crohn’s disease: a real-world propensity-matched analysis in the USA

BackgroundPatients with Crohn’s disease (CD) may develop fibrostenotic strictures. No currently available therapies prevent or treat fibrostenotic CD (FCD), making this a critical unmet need.AimTo compare health outcomes and resource utilisation between CD patients with and without fibrostenotic disease.MethodsPatients aged ≥18 years with FCD and non-FCD between 30 October 2015 and 30 September 2018 were identified in the Truven MarketScan Commercial Claims and Encounters Database. We conducted 1:3 nearest neighbour propensity score matching on age, sex, malnutrition, payer type, anti-tumour necrosis factor use, and Charlson Comorbidity Index score. Primary outcomes up to 1 year from the index claim were ≥1 hospitalisation, ≥1 procedure, ≥1 surgery, and steroid dependency (>100 day supply). Associations between FCD diagnosis and outcomes were estimated with a multivariable logistic regression model. This study was exempt from institutional review board approval.ResultsPropensity score matching yielded 11 022 patients. Compared with non-FCD, patients with FCD had increased likelihood of hospitalisations (17.1% vs 52.4%; p<0.001), endoscopic procedures (4.4% vs 8.6%; p<0.001), IBD-related surgeries (4.7% vs 9.1%; p<0.001), steroid dependency (10.0% vs 15.7%; p<0.001), and greater mean annual costs per patient ($47 575 vs $77 609; p<0.001). FCD was a significant risk factor for ≥1 hospitalisation (adjusted OR (aOR), 6.1), ≥1 procedure (aOR, 2.1), ≥1 surgery (aOR, 2.0), and steroid dependency (aOR, 1.7).ConclusionsFCD was associated with higher risk for hospitalisation, procedures, abdominal surgery, and steroid dependency. Patients with FCD had a greater mean annual cost per patient. FCD represents an ongoing unmet medical need.

Older age increases the risk of revision and perioperative complications after high tibial osteotomy for unicompartmental knee osteoarthritis

Among various patient risk factors affecting survival after high tibial osteotomy (HTO), the ideal age limit for HTO is unclear. This study was performed to evaluate the effect of age on survival rate and complications after HTO for medial unicompartmental osteoarthritis. Among of 61,145 HTO patients from Korean National Health Insurance database, 41,112 patients underwent the procedure before the age of 60 years (Group A), 13,895 patients between the age of 60 and 65 years (Group B), and 6138 patients after the age of 65 years (Group C). We compared the survival rate in person-years among the three groups from the date of primary surgery until subsequent total knee arthroplasty. Perioperative complications were also recorded. The adjusted hazard ratio (HR) were calculated using the multivariable Cox proportional hazard regression model, adjusting for the potential confounders: age, sex, type of medical insurance, region of residence, hospital type, comorbidities, and Charlson comorbidity index score. The total number of HTO increased 6.5-fold, especially in patients aged > 65 years (by 8.2-fold) from 2008 to 2018. The overall revision rate was 4.2% in Group A, 6.4% in Group B, and 7.3% in Group C. The 5- and 10-year revision rate was significantly lower in Group A (p < 0.001), but no difference between Groups B and C. After adjusting for potential confounders, multivariable regression analysis revealed that revision rate was significantly lower in Group A than Group B (HR: 0.57; p < 0.0001), but no difference between Groups B and C. The incidence of complications was also significantly lower in Group A than in other groups. The inferior survival rate and more perioperative complications after HTO was found in old patients (aged ≥ 60 years) than in young patients. Therefore, the patient age is one of the predicting factors for a high risk of failure after HTO.

Comparison of Clinical Features between the High and Low Serum KL-6 Patients with Acute Exacerbation of Interstitial Lung Diseases

Background. Serum Krebs von den Lungen-6 (KL-6) measurement is widely used to assess disease activity or prognosis in patients with interstitial lung diseases (ILDs). However, the clinical differences between high and low serum KL-6 levels at the time of acute exacerbation (AE) of ILD are not well known. Methods. Clinical parameters including age, sex, Charlson Comorbidity Index score (CCIS), blood biomarkers, high-resolution CT findings, and disease mortality were retrospectively compared between high and low KL-6 (cutoff value: 1000 U/mL) patients at the time of diagnosis of AE of ILDs. Results. Thirty-eight high serum KL-6 and 57 low serum KL-6 patients were included. There was no significant difference in 6-month mortality between them ( P = 0.685), whereas serum lactate dehydrogenase was a significant predictor of 6-month mortality in the high serum KL-6 patients (odds ratio (OR): 1.006; 95% confidence interval (CI): 1.003–1.009; P < 0.001), and CCIS (OR: 1.502; 95% CI: 1.242–1.838; P < 0.001) and sex (OR: 5.751; 95% CI: 1.121–105.163; P = 0.033) were significant predictors in low serum KL-6 patients. In addition, the incidences of congestive heart failure, symptomatic chronic pulmonary disease, cerebrovascular disease, and second metastatic solid tumours were significantly higher in nonsurvivors with low serum KL-6 than in other groups ( P < 0.05). Conclusions. The clinical features in patients with AEs of ILDs may differ depending on the serum KL-6 level, and clinicopathological examination according to this subtyping guided by the serum KL-6 level is essential.

Non-tuberculous mycobacterial pulmonary diseases in France: an 8 years nationwide study

Background The objective of the study was to describe the epidemiology, management and cost of non-tuberculous mycobacteria pulmonary disease (NTM-PD) in France. Methods A retrospective analysis was performed using the SNDS (“Système national des données de santé”) database over 2010–2017. Patients with NTM-PD were identified based on the ICD10 codes during hospitalizations and/or specific antibiotics treatment regimens. The study population was matched (age, sex and region) to a control group (1:3) without NTM-PD. Results 5628 patients with NTM-PD (men: 52.9%, mean age = 60.9 years) were identified over the study period and 1433 (25.5%) were treated with antibiotics. The proportion of patients still receiving treatment at 6 and 12 months was 40% and 22%, respectively. The prevalence of NTM-PD was estimated at 5.92 per 100,000 inhabitants and the incidence rate of NTM-PD remained stable over time between 1.025/100,000 in 2010 and 1.096/100,000 in 2017. Patients with NTM-PD had more co-morbidities compared to controls: corticoids (57.3% vs. 33.8%), chronic lower respiratory disease (34.4% vs. 2.7%), other infectious pneumonia (24.4% vs. 1.4%), malnutrition (based on hospitalization with the ICD-10 code reported during a hospital stay as a main or secondary diagnosis) (22.0% vs. 2.0%), history of tuberculosis (14.1% vs. 0.1%), HIV (8.7% vs. 0.2%), lung cancer and lung graft (5.7% vs. 0.4%), cystic fibrosis (3.2% vs. 0.0%), gastro-esophageal reflux disease (2.9% vs. 0.9%) and bone marrow transplant (1.3% vs. 0.0%) (p < 0.0001). The mean Charlson comorbidity index score was 1.6 (vs. 0.2 for controls; p < 0.0001). NTM-PD was independently associated with an increased mortality rate with a hazard ratio of 2.8 (95% CI: 2.53; 3.11). Mortality was lower for patients treated with antibiotics compared to untreated patients (HR = 0.772 (95% CI [0.628; 0.949]). Annual total expenses the year following the infection in a societal perspective were € 24,083 (SD: 29,358) in NTM-PD subjects vs. € 3402 (SD: 8575) in controls (p < 0.0001). Main driver of the total expense for NTM-PD patients was hospital expense (> 50% of the total expense). Conclusion Patients with NTM-PD in France were shown to have many comorbidities, their mortality risk is high and mainly driven by NTM-PD, and their management costly. Only a minority of patients got treated with antibiotics and of those patients treated, many stopped their therapy prematurely. These results underline the high burden associated with NTM-PD and the need for improvement of NTM-PD management in France.

The Extent of Honeycombing on Computed Tomography Cannot Predict the Treatment Outcome of Patients with Acute Exacerbations of Interstitial Lung Disease

Background. The purpose of this retrospective study was to clarify whether the presence of honeycombing on computed tomography (CT) can affect the prognosis of patients with acute exacerbations (AEs) of interstitial lung diseases (ILDs). Methods. Clinical parameters including age, sex, Charlson Comorbidity Index Score (CCIS), blood biomarkers, and 3-month mortality were retrospectively compared between the CT honeycombing present and absent groups at the diagnosis of AEs of ILDs. Results. Ninety-five patients who were on corticosteroid pulse therapy were assessed. Though log-rank tests showed that Kaplan–Meier survival curves of the high and low ground-glass opacity (GGO) score groups differed significantly in 3-month mortality in patients with AEs of idiopathic ILDs ( P = 0.007) and overall patients ( P = 0.045), there was no significant difference between the CT honeycombing present and absent groups in patients with AEs of idiopathic ILDs ( P = 0.472) and AEs of secondary ILDs ( P = 0.905), as well as of overall patients ( P = 0.600). In addition, whereas CCIS (OR, 1.436; 95% CI, 1.156–1.842; P < 0.001) was a significant predictor of 3-month mortality in the CT honeycombing absent group, serum LDH (OR, 1.005; 95% CI, 1.002–1.007; P = 0.001) was a significant predictor in the CT honeycombing present group. Conclusions. The clinical features of patients with or without honeycombing may differ due to the difference in prognostic factors, but these groups were found to have similar prognoses 3 months after AE onset, and clinicopathological examinations according to these groups are essential.

Relationship between Cataract Surgery and Mortality in Elderly Patients with Cataract: Nationwide Population-Based Cohort Study in South Korea

We aimed to investigate the relationship between cataract surgery and all-cause and cause-specific mortality in Korean elderly patients with cataract using the Korean National Health Insurance Service-Senior cohort database. Elderly patients (≥60 years) diagnosed with cataract from 2002 through 2012 were included. The baseline characteristics included demographics and systemic and ocular comorbidities. Adjusted Cox regression models with time-varying covariates for cataract surgery were used to assess the relationship between cataract surgery and mortality. The study cohort included 241,062 patients, of whom 127,941 were in the cataract surgery group and 113,121 were in the cataract diagnosis group. The incidence of all-cause mortality was 3.62 deaths/100 person-years and 3.19 deaths/100 person-years in the cataract surgery and cataract diagnosis groups, respectively. Cataract surgery was associated with a decreased hazard of all-cause mortality after adjusting for demographics as well as systemic and ocular comorbidities (hazard ratio (HR), 0.93; p < 0.001). A protective association was noted between cataract surgery and mortality from vascular (HR, 0.92; p < 0.001) or neurologic (HR, 0.64; p < 0.001) causes. Patients with cataract who were 85 years of age and older, women, those who had lower income, and a Charlson comorbidity index score of 5 or more, or those without glaucoma revealed the largest reductions in mortality hazards resulting from cataract surgery.